The VA healthcare system — Can we handle the truth?

Memorial Day weekend is an apt time to consider the recent accusations of wrongdoing in the VA healthcare system. It’s an opportunity to face the truth.

As a free American, I am connected to veterans. It has always been remarkable that young people give their life or health for their country, but now, in this me-centric era, it is stunning that they do. It is truth to say that veterans deserve our respect and our care. Consider also that recent wars have been fought on the backs of the underprivileged, a fact that strengthens the calling to care.

I am also connected to veterans’ healthcare. For it is in the VA system that I learned to be a doctor—a feeling doctor, an imperfect doctor, a human doctor. It’s ironic, and not often said, that the $48 billion-dollar VA healthcare system gives as much as it takes. It’s impossible to put a value on the benefit to society from the legions of caregivers who emerge from years of training in the VA system. Algorithms be damned; wealthy Americans benefit from what young doctors learn in the VA system. Veterans give when they serve in battle, then they give again as patients, as teachers.

And it’s not just the past that connects me to veterans’ healthcare. My wife Staci works as an attending physician in hospice and palliative care at the Louisville VA. When we share stories, I mostly tell of relieving the palpitations of the rich, she of relieving the suffering of dying veterans. Another irony of the VA: you don’t get Staci if you have private insurance.

That’s the thing about veterans’ healthcare. Buried deep within the maddening levels of bureaucracy are the Staci’s, the angels. And don’t think for a moment it’s just VA doctors who are special. There are armies of caring nurses, therapists, van-drivers–the list goes on and on.

So what about these stories of corruption? Veterans are dying on long waiting lists. Administrators are cooking the books to cover up the fact that you can’t deliver the same care to many as you can to few.

We should set out two givens. One is that the accusations remain alleged, and the other is that no right-minded person advocates for dishonesty. That said, it is most instructive to view the response to this “scandal.” Here we see real problems: a collective failure to note the obvious, the gaming of the story to simplistically knock down a single-payer system, or perhaps the dumbest of all, holding this up as an indictment of Obamacare.

Failure to see the obvious:

You simply cannot deliver suburban excesses—the antithesis of efficient and honest healthcare–to the growing numbers of veterans. Thank goodness. Both Dr. Harlan Krumholz and Dr. Kevin Pho remind us that if evidence, not hype, is considered, the VA system performs either better than, or comparable to, the private sector.

Yet this should be obvious to anyone who reads anything about US healthcare. It’s clear that the private system is broken. If you hold up the US private system—with its humanity-extracting EHRs, expanding layers of bureaucracy, conflicts of interest, expense, inequalities, and geographic and racial differences in care–as a model that the VA should aspire to, you are not mastering the obvious. My colleague at theHeart.org Dr. Melissa Walton Shirley suggests veterans should be moved to the private system. I wouldn’t do that; veterans deserve better than our mess.

Knocking the single-payer system:

This is a stretch. You are not saying a single-payer health system leads to dishonesty while the free-market system brings out the squeaky clean, are you? (I was going to hyperlink examples of predatory medicine, but that seemed like piling on.)

Let’s face the fact that humans will always behave according to human nature. We are mostly good but incentives exert influence. Reward heart catheterizations and you get heart catheterizations. Allow direct-to-consumer advertising and you get disease mongering.

The question is not so much which system could be better (single payer or free-market); that’s unknowable, really. The pragmatic question is which system–that covers all–can we accept and afford. My take as to why the VA system, with its wait times, student doctors, salaried employees, and sicker patients, performs as well as its more expensive wasteful competing system is that doctors don’t control nearly as much as we think we do. We immerse ourselves in the hubris of control. I’m John Mandrola, and only I can save you from AF.

In reality, the basics of medical care are not always that complicated or expensive—and the human body is remarkably resilient.

Yes, of course, patients die waiting for medical care. It’s utter nonsense to call that a scandal. Why? Because patients die regardless of medical care, and too often, as a result of medical care. This death-denying culture has led to a major humanitarian crisis, one playing out in nearly every ICU in this country.

But please don’t misunderstand. I’m not arguing that medical care is pointless, or that we should not try to extend and improve human life. Rather, it is time to adjust the mindset that more care or faster care is always better care.

We need to get past the idea that all of medicine should be big and bold, like treating a heart attack. The policy of indiscriminate mammography teaches such a lesson. American women were sold a pink-wrapped bill of goods. It turns out that mortality from breast cancer in the single-payer British system is essentially identical to that in the US. Now, when I see a woman with chemotherapy-induced heart disease, I can’t help but wonder whether this was an early-detected cancer that did not require therapy.

Until recently, I had to keep these thoughts to myself—as one of the ways the healthcare machine of ours survives is by making such thoughts seem heretical. Where are the pink bows for the masses of elderly patients with dementia entombed in nursing homes? Where are the pink bows for the Hepatitis C patients who can’t afford Gilead’s new wonder cure? Where are the pink bows for the underprivileged kids coming home from our wars with PTSD and drug addiction? The private system has no bows for these folks.

Indicting Obamacare:

This is a huge mistake. Obamacare fails because it lacked the courage to do enough. Its proponents avoided the truth. (Maybe they had to.) What policymakers set out to do was to correct a great American scar—that a country this rich does not provide basic healthcare to all its people. The problem was that Americans were not told the truth. A leader (or leaders) should have said that to get care to all people, excesses and inefficiency would need to be removed. Hospitals would not look like luxury hotels. Medicine and surgery would be for the ill, not the worried-well. Evidence, not eminence, would guide medical care. And prevention of disease would come not from doctors but from patients.

But Americans didn’t get the truth. We got magical thinking about metaphorical free lunches, insurance reform, cost-saving EHRs, patient-safety “quality forums,” and the like. Nonsense. All of it.

The VA system is the truth. Rationing is the truth. Triage is the truth. Imperfection is the truth.

And yes, death, too, is the truth.

Learning from mistakes

The most important means for improving medical care is learning from mistakes. As Dr. Krumholz notes, one of the reasons the VA story came to light was their accountability. They were courageous enough to record and document wait times, and in so doing, they exposed layers of bureaucracy separating veterans from caregivers.

The ultimate job of healthcare is to deliver health. This is not done in boardrooms or on white screens. It’s done in the exam room, face to face. It’s done by listening, seeing, touching and teaching. It’s done imperfectly, and not with immortality as the goal, but rather, the betterment of life in the short time we are present.

So I ask, are we sober enough to see the truth? Are we courageous enough to accept the truth? Can we learn from mistakes, or, are patients destined to the same fate as students?

JMM